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SAN JOAOuT COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTALWLALTH DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE —pD <br /> E Of FACILITY �I' �� `� WEEPS CODE �Q 7� <br /> DRESS a 1 a ! IFC TANK ID # 3 -1/0 7?-Q <br /> TANK SIZE 1 UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> - +M <br /> Is permit current? es o ermit # - acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) O ype'of Tank ISteel I VrFbrgL I 1SngL I Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o 10ailed precision test ? es o If yes, give dates) <br /> Jas a repair made to the tank system? Yes No 11f yes, what was repaired? <br /> as repair done under inspection? es No ere soil samples analyzed? es 0 TXE PH-GI PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfiII known I lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAI LECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received eso epth to Ground W ter a /Year �; verage Annual Precipitation kz 4 0-25 <br /> -Site Well(s) eso umber & Type ' Irr as ub <br /> S core S core S core <br /> istance to Wells) from Tank ;`� D ft; 3! ft; ft C 10 pts C 9 pts C i pts <br /> 0 if 0 if 0 if <br /> R condition R condition R ondition <br /> V. Site feature - Leaching Potential Analysis E is met E is met E is net <br /> inimum Depth to groundwer from the So l S le (feet;D_ z >100 1-100 25-50L <br /> Fractures in subsurface (applies o foothills or mountain areas) None Unknown Rresent <br /> verage Annuat Precipitation (inches) KXXXXX <10 9 10-25 Kxxxxxx 26-4012 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown S resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At leastore than <br /> xxxx None one S one <br /> COLUMN TOTALS»>TOTAL POINTS + + D <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS F9 pts or more 41 - 48 pts 40 pts or less <br /> f A11 4), Q 8 T X JE8 JT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA13 <br /> Sample Result: GASOLINE 1000 100 10 <br /> /'}1 /N D. 1MUM ALLOWABLE TPH LEVELS (PPM) <br /> TPN [E SEL 10,000 1000 —r-100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the teaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> 11 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> 12 if precipitation is > 40 inches, score 0 points. <br /> _\3 Levels for BTX8E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION "�6 f-'a�� �tICCG/ Il'I S I �J-Gn <br /> �1. Are BTX & E or TPH Concentrations > Allowable levels Yes o4.� <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE tES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />